Euglycemic Diabetic Ketoacidosis with SGLT2 Inhibitor Therapy in a Patient Undergoing Off-Pump Coronary Artery Bypass: A Case Report

Sodium-glucose cotransporter inhibitors are a class of oral hypoglycemic agents that are being increasingly used in the subset of patients with cardiovascular disease. Euglycemic diabetic ketoacidosis (EDKA) is a potentially uncommon side effect associated with their use, which requires prompt recognition and management. The authors present a case of a 66-year-old diabetic male patient, treated with dapagliflozin, undergoing coronary artery bypass grafting, who developed EDKA in the postoperative period. The classical signs and symptoms were absent as the patient was sedated and was on ventilator support. Persistent high anion gap acidosis in the absence of hemodynamic instability prompted further testing, which revealed ketosis and ketonuria. Treatment with a dextrose-insulin solution and cessation of further doses of dapagliflozin leads to an uneventful recovery and discharge. A high index of suspicion is warranted, especially in the setting of cardiac surgery, for the diagnosis and management of this potentially catastrophic complication.